Fields on page 3
Your Customer
Customer Reference Number (if
Number (if known)
(if known)
Family name
First given name
Second given name
Your date of birth
date of birth (DD MM
birth (DD MM YYYY)
No
Yes
Phone number
Phone number (including area code)
No
Yes
No
Yes
No
Yes
Married
Married
Date married or last with your partner
married or last your partner (DD MM
or last reconciled (DD MM YYYY)
Registered relationship
Australian state or
registered or last your partner (DD MM
or last reconciled (DD MM YYYY)
De facto
not married or in a
last reconciled with your (DD MM YYYY)
with your MM YYYY)
Fields on page 4
Your partner’s Customer
partner’s Customer Reference
Reference Number (if
Number (if known)
Mr
Mrs
Miss
Ms
Mx
Other
Family name
First given name
Second given name
Your partner’s date
partner’s date of birth
date of birth (DD MM YYYY)
No
Yes
Give details below
Other name
Type of name (for example, name at birth)
Other name
Type of name (for example, name before marriage)
Male
Female
Non-binary
details
Mobile
Home
Work
Is this account in your partner’s name? No
Yes
Email
No
Yes
No
Your partner’s permanent address
Your partner’s permanent address
Q15.Address3
Postcode
Your partner’s postal address (if different to above)
Your partner’s postal address (if different to above)
Q15.PostAddress3
Postcode
Your/your partner’s employment
Your/your partner’s illness
You are/your partner is in respite care
You are/your partner is in
You are/your partner is in prison
Other
Give details
Other
From (DD MM YYYY)
From (DD MM YYYY)
you
To (DD MM YYYY)
To (DD MM YYYY)
To (DD MM YYYY)
or indefinite
Fields on page 5
No
Not sure
Yes
Go to next question
No
Yes
Your partner’s tax file
partner’s tax file number
file number
Yes
Fields on page 6
• Income Support Payment, or
one If you need to provide
• Family Assistance only,
• Low Income Health Care Card only,
• Nil
• Income Support Payment, or
• Family Assistance only,
• Low Income Health Care Card only,
• Nil
• Income Support Payment, or
• Family Assistance only,
• Low Income Health Care Card only
• Commonwealth Seniors Health
Support at Home or Residential Care
Fields on page 7
No
Yes
Income support payment or
or claiming? one only
Low Income Health Care Card
Commonwealth Seniors Health Card
Tick one
Income support payment, ABSTUDY,
Low Income Health Care Card
Commonwealth Seniors Health Card
No
you are a sub-contractor but your income as a
Yes
You
Your partner
Employer’s name
Address
Address
24.D.1.EmpAddressL3
Postcode
Postcode
You
Your partner
Employer’s name
Address
Address
24.D.2.EmpAddressL3
Postcode
(including area code)
Fields on page 8
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
No
Seniors
Yes
Which financial year are you income details for
/
tax return
No
Income was below the tax
Only income was a
None of the above
Yes
income tax return
No
Income was below the tax
Only income was a
None of the above
Yes
Fields on page 10
$
$
AUD
$
$
$
$
$
$
$
$
AUD
$
$
$
$
$
$
$
Fields on page 11
Below the income limit
DummyCalcQ32
Above the income limit
No
your and your partner’s year be lower than it
Yes
stopped working, previously sold significant asset(s) to pay for medical expenses, ceased operating a business)
Fields on page 12
$
$
AUD
$
$
$
$
$
$
$
$
AUD
$
$
$
$
$
$
$
No
Is your
Yes
Fields on page 13
Australia
Other
Country where your
Australia
No
Not applicable – never
Yes
Give details below
Year last entered Australia
Passport number
Country of issue
No
Yes
No
What is your partner’s country of birth
Australia
Date citizenship granted (DD
Date citizenship
citizenship granted (DD
granted (DD MM YYYY)
Other
Country of citizenship
Date citizenship
citizenship granted (DD
granted (DD MM YYYY)
No
DummyCalcQ42
Yes
Permanent
Temporary
New Zealand passport
Temporary
Not sure
Visa subclass
Date visa granted
visa granted (DD MM
(DD MM YYYY)
No
than 20
Yes
No
you or your partner receive
Yes
Fields on page 14
$
$
AUD
= $
$
$
AUD
$
$
$
$
– $
$
AUD
AUD
$
$
$
$
– $
$
AUD
AUD
$
Fields on page 15
No
Do you or
Yes
No
No
Yes
If you were previously
No
If you were 48 hours of when did you stop
you were previously hours of recognised did you stop? (DD MM
previously engaged in more than recognised participation per stop? (DD MM YYYY)
Yes
Start date (DD MM
date (DD MM YYYY)
MM YYYY)
End date (if known)
date (if known) (DD MM
known) (DD MM YYYY)
Hours per fortnight
fortnight
Q53.Y.02
Q53.Y.03
Q53.Y.04
Unpaid work experience or internship
Unpaid work in a family business
Q53.Y.07
Setting up a business
No
If your partner was 48 hours of when did they stop
your partner was previously hours of recognised did they stop? (DD MM
was previously engaged in more recognised participation per stop? (DD MM YYYY)
Yes
Start date (DD MM
date (DD MM YYYY)
MM YYYY)
End date (if known)
date (if known) (DD MM
known) (DD MM YYYY)
Hours per fortnight
fortnight
Q53.P.02
Q53.P.03
Q53.P.04
Unpaid work experience or internship
Unpaid work in a family business
Q53.P.07
Setting up a business
Fields on page 16
Caring for an adult or child with a disability
Provide details for the other recognised participation type you are engaged in.
Q53.Y.10
Total hours
No or do not wish
Yes
Start date (DD MM
date (DD MM YYYY)
(DD MM YYYY)
End date (if known)
date (if known) (DD MM
known) (DD MM YYYY)
Start date (DD MM
date (DD MM YYYY)
(DD MM YYYY)
End date (if known)
date (if known) (DD MM
known) (DD MM YYYY)
Start date (DD MM
date (DD MM YYYY)
(DD MM YYYY)
End date (if known)
date (if known) (DD MM
known) (DD MM YYYY)
Caring for an adult or child with a disability
Provide details for the other recognised participation type you are engaged in.
Q53.P.10
Total hours
No or do not wish
Yes
Start date (DD MM
date (DD MM YYYY)
(DD MM YYYY)
End date (if known)
date (if known) (DD MM
known) (DD MM YYYY)
Start date (DD MM
date (DD MM YYYY)
(DD MM YYYY)
End date (if known)
date (if known) (DD MM
known) (DD MM YYYY)
Start date (DD MM
date (DD MM YYYY)
(DD MM YYYY)
End date (if known)
date (if known) (DD MM
known) (DD MM YYYY)
next question
Fields on page 17
No
Were you or
Yes
End date (if known) (DD / MM / YYYY)
55.Y.00
to of hours per (DD / MM / fortnight
(DD / MM / YYYY)
/
/
/
/
/
Is paid work casual or irregular
Unpaid leave
55.YUnpaidLeave.Hrs
55.YStart01.D
/
/
/
/
/
Study
55.YStudy.Hrs
/ /
/
/
/
/ /
/
Training
55.YTraining.Hrs
/ /
/
/
/
/ /
/
Volunteering
55.YVolunteering.Hrs
/ /
/
/
/
/ /
/
Unpaid work experience or internship
55.YUnpaidWorkExp.Hrs
/ /
/
/
/
/ /
/
Unpaid work in family business
55.YUnpaidFamBus.Hrs
/ /
/
/
/
/ /
/
Looking for work
55.YLooking.Hrs
/ /
/
/
/
/ /
/
Setting up a business
55.YSetUpBus.Hrs
/ /
/
/
/
/ /
/
Caring for an adult or child with a
55.YCarer.Hrs
/ /
/
/
/
/ /
/
Other
55.YOther.Hrs
/ /
/
/
/
/ /
/
* If you or your partner are engaged in ‘Other’ activities, give details below. You
None of the above
next 3-month period.
55.PPaidWork.Hrs
/ /
/
/
/
/
/
55.P.PaidWork
55.P.01
55.PUnpaidLeave.Hrs
/ /
/
/
/
/ /
/
55.P.02
55.PStudy.Hrs
/ /
/
/
/
/ /
/
55.P.03
55.PTraining.Hrs
/ /
/
/
/
/ /
/
55.P.04
55.PVolunteering.Hrs
/ /
/
/
/
/ /
/
55.P.05
55.PUnpaidWorkExp.Hrs
/ /
/
/
/
/ /
/
55.P.06
55.PUnpaidFamBus.Hrs
/ /
/
/
/
/ /
/
55.P.07
55.PLooking.Hrs
/ /
/
/
/
/ /
/
55.P.08
55.PSetUpBus.Hrs
/ /
/
/
/
/ /
/
55.P.09
55.PCarer.Hrs
/ /
/
/
/
/ /
/
or employment prospects (or both)) *
55.POther.Hrs
/ /
/
/
/
/ /
/
Your partner
None of the above
Fields on page 18
No
with
Yes
No
Yes
Income and Assets (Mod iA) form
Payslips or a letter from your and/or your partner’s
Centrelink/DVA schedule or similar schedule or
Original Notice of Assessment or if you are not required
Income tax returns or if you are not required to lodge
Payment summary
Payment summary and/or income tax return or if you
Documents to support the reason your income will be
Details of your child’s care arrangement (FA012) form
59
Your signature
Your partner’s signature
Date (DD MM YYYY)
of this and sign by hand
of this form, by hand
Date (DD MM YYYY)
of this and sign by hand
of this form, by hand
